Radiology (dra Bandong GI Radiology 19 July 08 From doc Bandong’s own words:  Ultrasound of the whole abdomen, there

is perforation, put in NPO for patients who have no history of cholecystectomy. Because we want the gallbladder to be distended in order to evaluate it.  The patient will not eat or have his breakfast, the gallbladder will be contracted because of the bile because you’re bile contains those that will breakdown the fat. Patient should be NPO atleast 4-6 hours.  Normal gallbladder: less than 5 cm in diameter o More than 5: hydrops  Normal wall of gallbladder: around 3 mm o Thickened wall with adjacent fluid in the GI wall: cholecystitis  Ultrasound: stones will appear as white  X-ray: stones will also appear as white  Common radiographic finding for cholecystolithiasis is: inter-luminal stones, wall would be thickened  Stones in common bile duct of gallbladder: choledocholithiasis (please check kung tama, di ko masyado maintindihan)  Stones in gallbladder: cholecystolithiasis  Stone in common bile duct: check intra-hepatic ducts, particularly in region of area of the pancreatic duct  Liver is mainly supplied by portal vein.  Mass in liver: check portal vein if there is possibility of metastasis or a visual ____(may dumaldal, dko narinig na haha) in CBD that would cause portal vein thrombosis  Portal vein size: 1.2  CBD size: 0.7 cm  In patients with previous cholecystectomy, size of CBD would be 1 cm.  In liver cirrhosis, the left lobe of the liver is enlarged, right lobe would be smaller and the margin of the conture of the liver would be nodular, epigenicity of the liver parenchyma is coarsened (jassie on tape: coarse? Coarse?) hahahaha .  Liver cirrhosis: Common feature: small liver with nodular and coarsened pattern with ascites  Importance for requesting for MRI: o In patients who has acute renal failure, we cannot give contrast materials because the minimum contrast material to be given on CT scan would be 16 ml, on MRI it’s I think 5-10 cc.  Structure: barum enema or UGI series, but rule out lower obstruction so barium enema first then UGI series  Most common reason why (peste! Peste! Kahit sa tape di sya maintindihan peste! Haha) emergency request for UTZ for cholecystitis: because GB may be distended more than 8-10 cm, surgical er may be needed. Also to rule out stones in kidney or GB. And to rule out if there is abdominal pain (WTF?!)  What are the common sonographic finding of acute cholecystitis: thickened wall, possibly a stone, and ____shadowing  Acute pancreatitis: echomogenous (echomogenous?! Wala na cranky na ko haha) enlarged pancreatitis or possibility of pseudo-cyst, does not have severe abdominal pain Chronic pancreatitis and pancreatic CA have both calcification on the pancreas. So rule out pancreatic CA first. But in some cases, there are different types of (tpos nawala na lang sya hahahaha) Normal GB wall: less than 3mm Status post cholecystectomy Liver CA: rule out if there is PV thrombosis, the normal size of the spleen is 11x5 cm. more than that: Ddx: lymphoma or leukemia Calcification in the liver and spleen: first impression would be kidney (sobrang di cguro eto yung snabi nya) if patient is Filipino

 Duodenum -- approximately 25 cm long; proximal   Ileum -- approximately 300 cm long; joins the cecum
at the ileocecal valve PLAIN FILM end of small intestine; joined to stomach by the pyloric sphincter. Jejunum -- approximately 200 cm long.

Sigmoid Volvulus  Distended sigmoid  Cause is generally considered a defect in the cholinergic receptors of Auerbach’s plexus (between the inner circular and the outer longitudinal muscle layers of the muscularis). Characteristically, primary peristaltic stripping waves are absent in either the upper (early) or the whole (late) esophagus. Tertiary waves may be present but in the late stages the esophagus is atonic. The lower esophageal sphincter fails to relax. In the late stages, the distal esophagus tends to make a right angle bend before entering the stomach due to the extreme tortuosity of the esophagus. This is called “bird’s beak” or “rat-tail” sign.

Allows you to visualize the gastric antrum and the duodenal cap while being able to sweep in double contrast phase

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LEFT LATERAL DECUBITUS VIEW OF THE ANTERIOR STOMACH WALL

This view is like the compression of the antrum in single contrast. The fundus is in double contrast and the duodenal sweep is sometimes seen to a better advantage C-LOOP/DUODENUM

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This view will provide you a double contrast view of the anterior wall of the stomach and sometimes of the posterior portion of the fundus There is a lesion on the posterior wall (Arrow) PRONE VIEW OF THE ENTIRE STOMACH AND DUODENUM

LEFT POSTERIOR OBLIQUE VIEW OF THE DUODENUM

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the patient in LPO position will demonstrate the duodenal cap and the rest of the duodenum in double contrast.

Radiology – GI Radiology by Dra Bandong

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HIATAL HERNIA

LYMPHOMA

Two main types: 1. Sliding Hiatal Hernia (99%)  EG junction lies above the diaphragm, or  Distal most esophagus measures more than 50% of the diameter of the tubular esophagus=patulous cardia=predisposed to GE reflux, or  Prominent gastric folds extend into distal esophagus from stomach  May be reducible or incarcerated; sliding refers to EG junction, not to reducibility 2. Paraesophageal Hiatal Hernia  Portion of stomach herniates through esophageal hiatus above diaphragm but EG junction continues to be subdiaphragmatic  Usually non-reducible  Not associated with GE reflux GASTRIC GI STROMAL TUMOR

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Most commonly involves terminal ileum Bowel wall becomes markedly thickened and submucosa infiltrated (picket-fence) “Thumb-printing“ may be seen Loops are widely separated and there may be mass effect Another form may have a large ulceration which is confined and produces so called “aneurysmal dilatation” of the bowel ULCER

MALABSORPTION

SMALL BOWEL FOLLOW THROUGH

Radiology – GI Radiology by Dra Bandong

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ASCARIASIS

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INDICATIONS FOIR DOUBLE CONTRAST (AIR CONTRAST) BARIUM ENEMA Rectal bleeding : gross or occult Polyps or carcinoma: suspected or known Inflammatory Bowel Disease: suspected or known Patient over 40y/o who can cooperate and turn over without assistance

Most common parasitic infestation in the world Most common in children ages 1 to 10 years Most often found in distal small bowel

Life cycle • Infection is through contaminated soil • Involves GI tract of host twice • First time as egg • Migrates through lungs • Adult travels up trachea

•

Returns

to GI tract for maturation (2 months) Rectosigmoid Colon

X-ray findings • Long, tubular filling defects, especially in distal small bowel • The worm ingests barium and the barium may be seen as a thin line of contrast in the center of the worm • Especially after the remainder of the barium exits the small bowel. See below (streak of barium in LUQ): BARIUM ENEMA

Malignant ulcer—is a carcinoma which presents with the radiographic appearance of an ulcer niche; these have the radiographic appearance of a benign ulcer but demonstrate microscopic foci of malignancy, usually at the edge of the ulcer Ulcerating malignancy—is a carcinoma having sufficient bulk to present as a mass which also contains a persistent collection representing an ulcer; the mucosa is frequently nodular and the folds do not radiate to the base of the ulcer Linitis plastica (scirrhous carcinoma)—is a diffuse involvement of the wall of the stomach, frequently with flattening of the mucosa, and poor distensibility and contraction of the wall; usually associated with significant fibrosis and muscular hypertrophy; very frequently a signet ring cell type • • DUODENAL ULCER DISEASE 2-3 times more frequent than gastric ulcers 3:1 male:female ratio

DIFFUSE SMALL BOWEL DISEASE Sprue • 3 diseases: Celiac Disease of Children, Nontropical sprue and Tropical Sprue • Celiac disease and Nontropical sprue improve on gluten-free diet • Tropical sprue improves with antibiotics and folic acid X-ray • The hallmark features are: dilatation and dilution, especially in jejunum • Segmentation of the barium column occurs because it moves more slowly through areas of excessive fluid and separates from the rest of the column-not commonly seen with newer barium mixtures • Fragmentation is an exaggerated example of the irregular stippling of residual barium in the proximal bowel (which is normal) • Intussusception is not uncommon but is usually not obstructive; sprue has increased risk of ca and lymphoma • Moulage sign is caused by dilated loop with effaced folds looking like tube into which wax has been poured Scleroderma • Affects esophagus, small bowel and colon, sparing the stomach • Atrophy of the muscular layers and replacement with fibrous tissue • Associated with malabsorption X-ray • Whole small bowel is usually dilated with close approximation of the valvulae (hide-bound appearance) (stack-of-coins) • Does not have increased secretions as does sprue • May be associated with pneumatosis intestinales Whipple’s Disease • Glycoprotein in the lamina propia of the small bowel is Sudan-negative, PAS-positive • Clinically: arthralgia, abdominal pain, diarrhea and weight loss • Treated with long term antibiotics-penicillin • Very rare X-ray • The hallmarks of the disease are nodules and a markedly thickened bowel wall (picket-fence)

Radiology – GI Radiology by Dra Bandong • • Small bowel may or may not be dilated Affects jejunum mostly •

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Amyloidosis • GI involvement is common • Associated with malabsorption X-ray • Marked thickening of the valvulae (picket-fence) • No dilatation or dilution • Affects entire small bowel Hypoproteinemia • Hypoalbuminemia resulting from liver or kidney disease lower than 1.5 grams per cent • Usually asymptomatic from intestinal edema itself X-ray • Changes are present throughout small bowel • Loops are separated due to edema of walls • Folds are quite thick (picket-fence) Giardiasis • Giardia lamblia is a flagellated protozoan, a normal parasite of the small bowel • Clinically: diarrhea and malabsorption • Treated with metronidazole (Flagyl) • Some patients have hypogammaglobulinemia and nodular lymphoid hyperplasia associated with giardiasis X-ray • Usually limited to duodenum and jejunum • Thickening of the folds • Marked spasm and irritability of the bowel • • Increased secretions is common Ischemic Bowel Disease • Thickening of the wall due to edema and hemorrhage • Localized perforations can produce air in the bowel wall or in portal venous system X-ray • Spasm and irritability early is replaced by an atonic bowel later • Lumen is narrowed • Folds are thickened, sometimes producing “thumbprinting” • Healing may result in stricture formation Intramural Bleeding • Suggested if there is duodenal obstruction following trauma • Localized lesions occur with trauma • Diffuse lesions are seen with anticoagulants X-ray • Uniform, regular, thickening of the folds • Separation of the loops • Mass effect • No spasm Radiation Enteritis

Changes are identical to ischemia since radiation changes are actually secondary to an arteritis with occlusion of small vessels • Localized to area of radiation portal, especially pelvis in female 2° endometrial carcinoma treatment • Previous adhesions from surgery may anchor small bowel in pelvic portal and predispose to XRT changes • Mucosa is most sensitive to radiation X-ray • Localized thickening of the folds 2° edema and hemorrhage • May result in strictures later in course Sigmoid Volvulus • Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract o Most commonly: sigmoid & cecum o Rarely: stomach, small intestine, transverse colon o Results in partial or complete obstruction o May also compromise bowel circulation resulting in ischemia • Sigmoid volvulus most common form of GI tract volvulus • Accounts for up to 8% of all intestinal obstructions • Most common in elderly persons (often neurologically impaired)

Supine abdominal radiograph shows an collection of air within the subhepatic space.

elliptical

Coned view of the lower abdomen shows the lateral umbilicus sign (arrow), which is a sign of a large pneumoperitoneum on a plain abdominal radiograph

Diagram of the right upper quadrant shows a triangleshaped collection of air in the Morison’s pouch, as seen on a plain supine abdominal radiograph. This collection is usually bound by the 11th rib, and it may be triangular (doge’s cap), crescent shaped, or semicircular.

Rigler’s Sign

Diagrams of the right upper quadrant show the location of the oblong collection of air in the right subhepatic space seen on a plain supine abdominal radiograph

The gallbladder (GB) is filled with echogenic sludge and a gallstone (red arrow) is impacted in the gallbladder neck. The gallbladder wall (red arrowheads) is markedly thickened indicative of wall edema and there are pericholecystic fluid (blue arrows) pockets surrounding the gallbladder. Sonographic Findings: 1. Shotgun sign in intrahepatic biliary ducts (IHBD) become tortuous and their diameter exceeds 2 mm or exceeds 40% of the diameter of the adjacent PV. Color Doppler is used to confirm the absence of blood flow in the enlarged biliary tubes 2. Confluence of enlarged intrahepatic biliary ducts create a stellate appearance of merging tubes 3. CBD is considered diluted in adults if its diameter > 7 mm.

Huge fluid collection (F) surrounding the pancreas (P) RLQ Pain Appendicitis • The classic presentation is of a 10-30 year old person with right lower quadrant pain, nausea, vomiting, and leukocytosis. The presence of fever is evidence of perforation.

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Inferior vena cava (V), abdominal aorta(A), and the superior mesenteric artery (a) The junction of the splenic vein (SV) with the superior mesenteric vein marks the commencement of the portal vein (PV) and is recognized by its teardrop shape The head (H), body (B), and tail (T) of the pancreas course anterior and parallel to the splenic vein (SV)

Transverse image reveals normal appendix (between red arrows and + cursors) and its echogenic submucosa (red arrowhead). The head of the pancreas (H) is enlarged as revealed by the red arrowheads and decreased in echogenicity because of edema. The surrounding structures are superior mesenteric vein (v), superior mesenteric artery (A), and inferior vena cava (IVC). Sonographic Diagnosis: • Visualization of an aperistaltic tubular structure > 6 mm in diameter or visualization of an appendix with a fecolith confirms the diagnosis • Generally, the abnormal appendix is not at all subtle • The wall appears hyperechoic and may be strikingly so with impending perforation • A loculated fluid collection may represent abscess from a perforated appendix or other bowel source such as IBD (ischemic bowel dse) , or GYN source such as TOA (tubo-ovarian abscess)